Soft Tissue Microvascular Reconstruction of Orbital Exenteration Defects

Orbital Exenteration for Craniofacial Lesions: A Systematic Review and Meta-Analysis of Patient Characteristics and Survival Outcomes

BACKGROUND

The outcomes of orbital exenteration (OE) in patients with craniofacial lesions (CFLs) remain unclear. The present review summarizes the available literature on the clinical outcomes of OE, including surgical outcomes and overall survival (OS).

METHODS

Relevant articles were retrieved from Medline, Scopus, and Cochrane according to PRISMA guidelines. A systematic review and meta-analysis were conducted on the clinical characteristics, management, and outcomes.

RESULTS

A total of 33 articles containing 957 patients who underwent OE for CFLs were included (weighted mean age: 64.3 years [95% CI: 59.9-68.7]; 58.3% were male). The most common lesion was squamous cell carcinoma (31.8%), and the most common symptom was disturbed vision/reduced visual acuity (22.5%). Of the patients, 302 (31.6%) had total OE, 248 (26.0%) had extended OE, and 87 (9.0%) had subtotal OE. Free flaps (33.3%), endosseous implants (22.8%), and split-thickness skin grafts (17.2%) were the most used reconstructive methods. Sino-orbital or sino-nasal fistula (22.6%), flap or graft failure (16.9%), and hyperostosis (13%) were the most reported complications. Regarding tumor recurrences, 38.6% were local, 32.3% were distant, and 6.7% were regional. The perineural invasion rate was 17.4%, while the lymphovascular invasion rate was 5.0%. Over a weighted mean follow-up period of 23.6 months (95% CI: 13.8-33.4), a weighted overall mortality rate of 39% (95% CI: 28-50%) was observed. The 5-year OS rate was 50% (median: 61 months [95% CI: 46-83]). The OS multivariable analysis did not show any significant findings.

CONCLUSIONS

Although OE is a disfiguring procedure with devastating outcomes, it is a viable option for carefully selected patients with advanced CFLs. A patient-tailored approach based on tumor pathology, extension, and overall patient condition is warranted.

Orbital Extenteration Defects: Ablative and Reconstructive Flowchart Proposal

ABSTRACT

Orbital exenteration is a radical and disfiguring operation. It is still under debate the absence of correlation between the term describing the resulting orbital defect and the type of reconstruction. Authors' goal was to propose a consistent and uniform terminology for Orbital Exenteration surgery in anticipation of patients' tailored management. Twenty-five patients who underwent orbital exenteration between 2014 and 2020 were reviewed. A parallel comprehensive literature review was carried on. Five different types of orbital exenteration where outlined. Multiple reconstructive procedures were enclosed. An algorithm for orbital reconstruction was proposed based on anatomic boundaries restoration. Eyelid removal was first considered as an independent reconstructive factor, and both orbital roof and floor were indicated as independent reconstructive goals, which deserve different defect classification. In our opinion, this algorithm could be a useful tool for patient counseling and treatment selection, which might allow a more tailored patient care protocol.

LEVEL OF EVIDENCE

Level III.

Reconstruction of Orbital Exenteration Defect With Cheek or Combined Cheek and Forehead Advancement Flaps

PURPOSE

To review the outcomes of orbital exenteration defect reconstruction using cheek or combined cheek-forehead advancement flap.

METHODS

Charts of 14 patients who underwent reconstruction of the exenterated orbit with cheek advancement flap were reviewed. In surgery, a cheek flap elevated via a nasofacial sulcus incision, and preperiosteal dissection was advanced over the defect. The upper orbital defect, if necessary, was covered with a forehead flap, which was dissected through an incision in the midline or temporal forehead and advanced inferiorly.

RESULTS

In all patients (7 women, 7 men; mean age, 65 years), total (n = 7) or extended (n = 7) exenteration was performed for a malignant tumor. In 12 patients (86%), the defect was primarily closed with cheek flap alone (n = 6) or cheek plus forehead (n = 6) advancement flaps. Eight patients received radiotherapy before and after surgery. Four patients (29%) had a total of 6 postoperative complications (skin graft infection, orbital cavitary abscess, osteomyelitis, chronic skin ulcer, and 2 sino-orbital fistulae). The mean follow-up duration was 43 months (range, 11-79 months).

CONCLUSIONS

Cheek advancement flap can be used alone or together with a forehead advancement flap to cover the orbital defects after total or extended exenteration. This repair may be resistant to radiotherapy-related complications in some cases.

Orbital exenteration: an updated review with perspectives

Orbital exenteration is a radical and disfiguring surgery mainly performed in specialized tertiary care centers. Orbital exenteration has long been considered the treatment of choice for managing periocular tumors invading the orbit or primary orbital malignancies. Over the past decades, attention has been directed toward reducing the perioperative morbidity by developing new surgical devices and new strategies and promoting cosmetic rehabilitation by providing adequate facial prostheses. Despite these advances, several studies have questioned the role of orbital exenteration in improving overall survival. The last decade has been marked by the emergence of a new paradigm: the "eye-sparing" strategies based on conservative surgery with or without adjuvant radiotherapy and/or targeted therapies and immunotherapies. We summarize the data on orbital exenteration, including epidemiology, etiologies, use of surgical ablative and reconstructive techniques, complications, outcomes, and the related controversies.

Reconstructive options following orbital exenteration

PURPOSE OF REVIEW

The purpose of this review is to examine current trends in reconstruction following orbital exenteration. Defects ranging from isolated exenteration to more complex midface resections are explored.

RECENT FINDINGS

Goals of reconstruction include separating the sino-orbital cavities and creating a safe, stable wound that can withstand adjuvant radiation. When planning for orbital rehabilitation, it is important to create a concave cavity that can accommodate a prosthesis. This is primarily achieved through secondary granulation or split-thickness skin grafts. Recently, the use of dermal allografts has been investigated and shown good success with epithelization of the orbital cavity. For complex orbitomaxillectomy defects, musculocutaneous free tissue flaps remain the mainstay for reconstruction.

SUMMARY

Reconstructive options following orbital exenteration are based on extent of the defect, need for postoperative radiation, and plans for orbital rehabilitation with prosthesis.